WCC Form 2 - Alabama Department of Labor



|WCC Form 2

Rev. 9/2006 STATE OF ALABAMA

EMPLOYER’S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE

Ombudsman 1-800-528-5166 | | |

|CLAIM REFERENCE |

|1. Insured Report Number       |2. Filing Office Claim Number       |3. OSHA Log Case Number       |

|EMPLOYER |

|4. Employer Business Name       |ADDRESS, IF LOCATION DIFFERENT FROM BUSINESS ADDRESS |

|5. Physical Address 1       |10. Mailing Address 1       |

|6. Physical Address 2       |11. Mailing Address 2 or Telephone Number       |

|7. City       8. State    9. Zip       |12. City       13. State    14. Zip       |

|15. Federal ID Number       |16. U.C. Account Number       |17. NAICS       |

|INSURER / FILING OFFICE |

|18. Insurer Name       |21. Filing Office Name       21a. Service Co. #      |

|19. Insurer Federal ID Number       |22. Mailing Address 1       |

|20. Type Insurer Insurance Co. Ins Co #       |23. Mailing Address 2 or Telephone Number       |

|Self-Insurer SI #       |24. City       25. State    26. Zip       |

|Group Fund GF #       |27. Filing Office Federal ID Number       |

|EMPLOYEE / WAGES |

|28. First Name       |32. Employee ID Number       |

|29. Middle Name       |33. Type Employee ID Number |

|30. Last Name       |SSN Passport Number Green Card |

|31 Last Name Suffix (ie. Jr., Sr., III)       |Employment Visa Assigned by Jurisdiction |

|34. Mailing Address 1       |40. Gender |41. Date of Birth |

|35. Mailing Address 2       |Male |      |

|36. City       37. State    38. Zip       39. Phone       |Female |42.Nbr of Dependents     |

|43. Marital Status |44. Date Hired |

|Unmarried (Single or Divorced or Widowed) Married Separated Unknown |      |

|45. Occupation Description       |46. Number of Days Worked Per Week   |

|47. Wages $       |49. Received Full Pay For Day of Injury? Yes No |

|48. Hourly Daily Weekly Bi-weekly Monthly |50. Did Salary Continue? Yes No |

|INJURY / TREATMENT |

|51. Date of Injury |52. Time of Injury |53. Time Employee Began Work |54. Date Disability Began |55. Date of Death |

|      |      a.m. p.m. unk |      a.m. p.m. |      |      |

|PLACE OF ACCIDENT, INJURY, OR EXPOSURE |61. Injury Occurred on Employer’s Premises? |

| | |

|56. Site Address       |Yes No |

| | |

|57. City       58. State    59. Zip       60. County       | |

| |62. Date Employer Notified       |

|63. DESCRIBE WHAT THE EMPLOYEE WAS DOING JUST BEFORE THE INCIDENT AND HOW THE INJURY OCCURRED. ( Ex. While climbing a ladder and carrying roofing materials, ladder |

|slipped on wet floor causing worker to fall 20 feet.) |

|      |

|PROVIDE DESCRIPTION CODES to identify Nature of Injury, Part of Body that was affected, and Cause of Injury. |

|(FOR COMPLETE LIST OF CODES, GO TO HTTP:// DIR.WC |

| |

|64. Nature of Injury Code    65. Part of Body Code    66. Cause of Injury Code|

|   |

|67. Initial Treatment |68. Name of Treatment Facility       |

|No Medical Treatment First Aid By Employer |69. Address       |

|Minor Clinic / Hospital Emergency Room |70. City       71. State    72. Zip       |

|Hospitalized > 24 Hours Major medical/Lost time | |

|Hospitalized Overnight | |

|73. Name of Physician or Other Health Care Professional |74. Has Injured Returned to Work |If so, 75. Date       |

|      |Yes No |76. Time       a.m. p.m. |

|OTHER |

|77. Date Prepared |78. Preparer’s First Name 79. Last Name 80. Title |81. Preparer’s Telephone Number |

|      |                  |      |

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